As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED,
AND HOW YOU CAN GET ACCESS TO YOUR INDENTIFIABLE HEALTH INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Personalized Primary Care is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of your legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of this notice of privacy practices that we have in effect at this time.

To summarize, this notice provides you with the following important information:

How we may use and disclose your identifiable health information

Your privacy rights in you identifiable health information

Our obligations concerning the use and disclosure of your identifiable health information.

The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy practices. Any revisions or amendments will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will have a current notice in our office, and you may request a copy of our most current notice during any office visit.

C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and disclose your identifiable health information.

1. Treatment. Our organization may use your identifiable health information to treat you. For example, we may ask you to undergo laboratory test (such as blood of urine tests), and we may use the results to help us reach a diagnosis. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents.

2. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items.

3. Health Care Operations. Personalized Primary Care may use and disclose your identifiable health information to operate our business. Our organization may use you health information to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for our practice.

4. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits.

WITH YOUR CONSENT:

5. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member that is helping you pay for your health care, or who assists in taking care of you.

6. Disclosures Required By Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL
CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our organization may disclose your identifiable health information to public health authorities that are
authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths

Reporting child abuse or neglect

Preventing or controlling disease, injury, or disability

Notifying a person regarding potential exposure to a communicable disease

Notifying a person regarding a potential risk for spreading or contacting a disease or condition

Reporting reaction to drugs or problems with products or devices

Notifying individuals if a product or a device they may be using has been recalled

Notifying appropriate government agency (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose the information.

2. Health Oversight Activities. Personalized Primary Care may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions, or other activities for the government to monitor government programs, compliance with civil right laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Personalized Primary Care may disclose your identifiable health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official:

Regarding a crime victim in certain situation, if we are unable to obtain the person’s agreement

Concerning a death we believe might have resulted from criminal conduct

Regarding criminal conduct at our offices

In response to a warrant, summons, court order, subpoena or similar legal process

To identify/locate a suspect, material witness, fugitive or missing person

In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator.

5. Serious Threats to Health or Safety. Personalized Primary Care may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

6. Military. Personalized Primary Care may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities.

7. National Security. Personalized Primary Care may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

8. Inmates. Personalized Primary Care may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure of these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety of other individuals.

E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION

You have the following rights regarding the identifiable health information that we maintain about you:

1. Confidential Communications. You have the right to request that Personalized Primary Care communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.

2. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Personalized Primary Care may deny your request to inspect and/or copy in certain limited circumstances.

3. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. Your request for an amendment must be in writing. You must also provide use with a reason that supports your request for amendment. We may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.

4. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an “accounting of disclosures” you must submit your request in writing. All requests must state a time period which may not be longer than six years and may not include dates before April 14, 2003.

5. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with Personalized Primary Care, contact Erin M. Robson at 407-566-2454 or officemgr@personalizedprimarycare.com. All complaints must be submitted in writing. You will not be penalized for filling a complaint.

6. Right to Provide an Authorization for Other Uses and Disclosures. Personalized Primary Care will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note, we are required to retain records of your care.